While I agreed that Jeanette should go, I was not as sure that it was my duty to make sure she did.

So what did I do?

Jeanette was one of countless patients who have declined the advice of the medical profession. For years, such people were termed ''noncompliant'' and even ''recalcitrant.'' The implication was that their decisions were necessarily misguided.

But Jeanette was actually one of my most agreeable patients. She dutifully took all of her medications and carefully watched her diet. I could not remember an instance in almost 12 years when she had questioned me.

What Jeanette was doing was making a personalized decision based on her own assessment of the various options. Over the last several years, researchers have begun to study how patients balance the risks and benefits of proposed interventions.

Syncope, the scientific term for a brief loss of consciousness, was potentially dangerous, especially for someone like Jeanette, who had never before passed out. Most worrisome was the possibility that her syncope had been caused by an arrhythmia, an abnormal heartbeat that can cause temporary loss of blood flow to the brain. Some arrhythmias, if not immediately identified and treated, are life threatening.

I explained this possibility to Jeanette over the phone. But I also told her that most elderly patients with syncope leave the hospital without a definitive diagnosis. That is, they would have done just fine at home.

This was clearly what Jeanette wanted to hear. She told me how she had exerted herself all day, helping to prepare the Thanksgiving meal. She had gotten sweaty and lightheaded during dinner and then passed out. ''I just overdid it,'' she explained. ''I'll be just fine.''

I reminded her once more that the safest thing was to go the hospital. There was even a chance she could die, I warned. But Jeanette had made up her mind. She thanked me for my concern and told me she would see me at her next appointment, in roughly three weeks.

I told the paramedics they could leave, and reminded Jeanette or her daughter to call again immediately if there were problems.

After I hung up the phone, I reflected on other patients who had chosen a potentially risky course of action.

One was a woman who had suffered a heart attack and had additional heart muscle at risk. The cardiologists wanted to perform a catheterization to visualize her anatomy. This test might have revealed a blockage that could have been opened by angioplasty or surgery.

My patient wanted no part of this. She declined and went home. Once she got there, she discontinued many of the medications she had been given to prevent future heart attacks. They had too many side effects, she said.

Although this woman has continued to decline my recommendations, she remains well.

Another patient, however, was not so lucky. This woman had fallen after leaving my office, landing on her wrist. She was quite ill with multiple medical problems, one of them mandating that she take blood thinners.

I was called to the hospital lobby to see her. Her wrist was sore but not swollen. I told her she needed to go to the emergency room for an X-ray to make sure that her wrist was not broken. A fracture could cause serious bleeding in her case, I explained.

But the patient begged me to let her go home, saying she was simply exhausted and could not bear the thought of waiting for hours to be evaluated. Efforts to persuade her failed.

When she left, I extracted my usual promise: she would let me know if her wrist worsened. When her family and I called later that night, she said she was fine.

But she was not. Sometime over the next couple of days, she died. No autopsy was done, but it is likely that the death was related to the accident. Both the family and I felt guilty, but we agreed she had made a clear choice.

And what about Jeanette? When I surveyed the waiting room on the morning of her scheduled appointment, there she was, looking as well as ever.

In my office, she told me that she had been absolutely fine since Thanksgiving. When the appointment ended, she gave me a hug and wished me happy holidays.